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Original Research: Pulmonary Procedures |

A Randomized Trial of 1% vs 2% Lignocaine by the Spray-as-You-Go Technique for Topical Anesthesia During Flexible BronchoscopyLignocaine Concentration During Bronchoscopy FREE TO VIEW

Harpreet Kaur, MSc; Sahajal Dhooria, MD, DM; Ashutosh N. Aggarwal, MD, DM, FCCP; Dheeraj Gupta, MD, DM, FCCP; Digambar Behera, MD, FCCP; Ritesh Agarwal, MD, DM, FCCP
Author and Funding Information

From the Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

CORRESPONDENCE TO: Ritesh Agarwal, MD, DM, FCCP, Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh-160012, India; e-mail: agarwal.ritesh@live.com


FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(3):739-745. doi:10.1378/chest.15-0022
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BACKGROUND:  The optimal concentration of lignocaine to be used during flexible bronchoscopy (FB) remains unknown. This randomized controlled trial compared the efficacy and safety of 1% and 2% lignocaine solution for topical anesthesia during FB.

METHODS:  Consecutive patients were randomized to receive either 1% or 2% lignocaine solution through the bronchoscope by the “spray-as-you-go” technique. The primary outcome of the study was the assessment of cough by the operator and the patient using the visual analog scale (VAS) and pain assessment using the faces pain rating scale. The secondary outcomes included total lignocaine dose, oxygenation status, adverse reactions related to lignocaine, and others.

RESULTS:  Five hundred patients were randomized (median age, 51 years; 71% men) 1:1 to either group. The median operator VAS score for cough was significantly higher (25 vs 21, P = .015) in the 1% group; however, the patient VAS score was not significantly different (32 vs 27, P = .065). The pain rating was similar between the two groups. The median cumulative dose of lignocaine was significantly higher in the 2% group (397 mg vs 312 mg, P = .0001; 7.1 mg/kg vs 5.7 mg/kg, P = .0001). About 28% of patients in the 2% group exceeded the maximum recommended dose (> 8.2 mg/kg) of lignocaine. No adverse event related to lignocaine overdose was seen in either group.

CONCLUSIONS:  One percent lignocaine was found to be as effective as 2% solution for topical anesthesia during FB, albeit at a significantly lower dose as the latter. Thus, 1% lignocaine should be the preferred concentration for topical anesthesia during FB.

TRIAL REGISTRY:  ClinicalTrials.gov; No.: NCT01955824; URL: www.clinicaltrials.gov

Figures in this Article

Flexible bronchoscopy (FB) is a widely used procedure for the diagnosis and treatment of a variety of bronchopulmonary disorders because of patient comfort, low rate of complications, and lack of requirement of general anesthesia.1 Most patients tolerate the procedure well although cough is reported to be an extremely distressing symptom.2 It is likely that the acceptance of bronchoscopy would be significantly improved with control of cough. A combination of midazolam and hydrocodone has been shown to significantly reduce cough during FB, especially when invasive diagnostic procedures are performed.3 However, in several centers including ours, due to logistics, sedation is not routinely used during basic diagnostic bronchoscopy; procedures such as BAL, endobronchial biopsy (EBB), and transbronchial lung biopsy (TBLB) are performed under topical anesthesia.

Lignocaine is the most common local anesthetic used during FB because of its quick onset, short duration of action, and lesser toxicity compared with other agents.4 The use of topical lignocaine during FB has been shown to improve patient’s tolerance and satisfaction of the procedure.5,6 Furthermore, it has been demonstrated that nebulized lignocaine can reduce the need for supplemental topical anesthesia, administered as injection through the bronchoscope.7,8 The optimal concentration of lignocaine as topical anesthesia, however, remains speculative, and 1% and 2% concentrations of lignocaine solutions are commonly used. The British Thoracic Society guidelines recommend the use of 1% lignocaine while the American College of Chest Physicians (CHEST) consensus statement endorses a wide range of lignocaine concentrations (1%-10%) that have been found to be effective without advocating any particular value.9,10

There is little data on the efficacy of lower concentrations (1%-2%) of lignocaine.11 It is important that the superiority of a particular concentration be ascertained, as effectiveness of lower concentrations would allow the use of higher volumes with lesser chances of complications. In this randomized controlled trial (RCT), we report the efficacy and safety of 1% vs 2% lignocaine for topical anesthesia in patients undergoing FB.

Setting

This was an investigator-initiated, single-center, randomized double-blind trial conducted in the bronchoscopy suite of this institute between May and November 2014. The study protocol was approved by the Ethics Review Committee (Ref. No. NK/1473/Res/687), and written informed consent was obtained from all the patients. As a protocol in our bronchoscopy suite, patients undergoing BAL, EBB, and TBLB are not routinely sedated, and bronchoscopy is performed under topical anesthesia. Patients undergoing other procedures such as conventional transbronchial needle aspiration (TBNA), endobronchial ultrasonography-guided TBNA, and other interventions are routinely sedated with midazolam and pentazocine.

Patients

Patients were eligible for inclusion into the study if they met all of the following criteria: (1) indication for flexible bronchoscopy, (2) age group of 12 to 90 years, and (3) hemodynamic stability (defined as systolic BP > 100 mm Hg and < 180 mm Hg). Patients with any of the following were excluded: (1) pregnancy, (2) hypoxemia (oxygen saturation [by pulse oximetry] < 92% with Fio2 of 0.3), (3) patients undergoing TBNA and other interventions, and (4) failure to provide informed consent.

Randomization

Patients were randomized in 1:1 ratio to receive either 1% or 2% lignocaine solution. The randomization sequence was computer-generated, and the assignments were placed in sealed opaque envelopes. Both the patient and the bronchoscopist were blinded to the concentration of lignocaine solution used for the procedure.

Study Protocol

Demographic profile including age, sex, height, weight, smoking history, BMI, and the type of procedure performed (airway inspection, BAL, EBB, TBLB) was recorded for all patients. Patients in both the groups were prepared in a similar fashion except for the concentration of lignocaine used. All patients were kept fasting overnight. The patients were nebulized with 2.5 mL of 4% lignocaine (Lox, 42.7 mg/mL; Neon Laboratories Ltd) for 15 min prior to the procedure. Lignocaine spray (10%, Lox, 100 mg/mL; Neon Laboratories Ltd) was sprayed twice (10 mg/puff) over the oropharynx. Approximately 5 mL of lignocaine gel (2%; Neon Laboratories Ltd), equivalent to 100 mg of lignocaine, was administered in the nasal cavity prior to the introduction of the bronchoscope. Patients thereafter received 2-mL aliquots of 1% or 2% lignocaine solution (Wocaine; Wockhardt) delivered through the bronchoscope using the ‘‘spray-as-you-go’’ technique. Four aliquots of 2 mL of lignocaine were administered: one each at the vocal cord, tracheal carina, and in the right and left main bronchus. Extra lignocaine aliquots were given as a ‘‘rescue’’ treatment to suppress cough, at the discretion of the operator. The sum of the standard dose (2.5 mL of 4% nebulized lignocaine [106.75 mg] plus 5 mL of 2% lignocaine gel [100 mg] plus two puffs of 10% lignocaine spray [20 mg] plus 8 mL of 1% [85.2 mg] or 2% [170.4 mg] lignocaine) and rescue dose made up the total dose of lignocaine used. Patients were monitored for any adverse effects related to lignocaine use (like arrhythmia, involuntary movements, convulsions, anaphylaxis, and bronchospasm). Heart rate, respiratory rate, BP, and oxygen saturation (by pulse oximetry) were monitored throughout the procedure.

The bronchoscopist was asked to assess the intensity of the patient’s cough during FB using a visual analog scale (VAS) immediately after the procedure. The VAS for cough was rated on a horizontal line, 100 mm in length anchored by “No cough” at one end and “Worst cough” at the other.12 Once stable, the patients recorded their quantum of cough and pain using the VAS and the faces pain rating scale, respectively. The faces pain rating scale consists of six faces with brief word instructions provided with the scale representing increasing intensity of pain on an ordinal scale from 0 to 5.13

Study Outcomes

The primary outcome of the study was patient comfort during the procedure measured by the intensity of cough rated on a VAS by both the operator and the patient and the pain assessment by the patient using the faces pain rating scale. The secondary outcomes included total lignocaine dose; changes in respiratory rate, heart rate and BP, and oxygenation status following the procedure; and adverse reactions related to lignocaine (arrhythmia, involuntary movements, convulsions, anaphylaxis, and bronchospasm).

Statistical Analysis

Statistical analysis was performed using the commercial statistical package SPSS for MS-Windows, version 22 (IBM Corporation). P < .05 was considered as statistically significant. Data are presented in a descriptive fashion as number with percentage or median with interquartile range. χ2 (or the Fisher exact test) was used to analyze categorical variables and the Mann-Whitney U test was used for comparing the numerical data. The change in variables before, during, and after the procedure was analyzed with multiple repeated measure analysis of variance.

During the study period, 500 consecutive patients (250 in each group, 70.6% men) with a median (interquartile range) age of 51 years (40-60) were included in the study (Fig 1). The baseline characteristics including the demographic characteristics, physiologic parameters, and the type of bronchoscopic procedures performed were similar in the two groups (Table 1). Heart rate, respiratory rate, and BP increased after the procedure as compared with baseline in both the study groups. However, the change was not significantly different between the two groups (Table 2).

Figure Jump LinkFigure 1 –  CONSORT diagram demonstrating the flow of participants in the study. EBUS = endobronchial ultrasonography; TBNA = transbronchial needle aspiration.Grahic Jump Location
Table Graphic Jump Location
TABLE 1 ]  Baseline Characteristics of the Study Population

All values are expressed as median with interquartile range, unless otherwise stated.

Table Graphic Jump Location
TABLE 2 ]  Serial Physiologic Parameters Measured Before, During, and After FB in the Two Groups

All values are mean (SD) unless otherwise stated. P < .05 was taken as significant. The differences between the means was analyzed using multiple repeated measure analysis of variance with Bonferroni adjustment for multiple comparisons; the within-groups factor was time (baseline, during, and after), and the between-groups factor was the lignocaine groups (1% vs 2%). FB = flexible bronchoscopy.

a 

Value during procedure significantly different from that at baseline within the groups.

b 

Value after procedure significantly different from that at baseline within the groups.

The median operator VAS score for cough was significantly higher in the 1% group (1% group: 25 vs 2% group: 21; P = .015); however, the median patient VAS score for cough was similar between the two groups (Table 3). The faces pain rating score was similar in the two groups (Table 3). The median total dose of lignocaine used was significantly higher in the 2% group (2% group: 397 mg vs 1% group: 312 mg; P = .0001). Similarly, the lignocaine dose adjusted for body weight was also significantly higher in the 2% group (Table 3). The number of patients with total administered dose > 8.2 mg/kg lignocaine was also significantly higher in the 2% group (Table 3). Heart rate, respiratory rate, and BP after the procedure were similar in the two groups. No adverse events related to lignocaine such as bronchospasm, arrhythmias, involuntary movements, or convulsions were observed in any patient.

Table Graphic Jump Location
TABLE 3 ]  Primary and Secondary Outcomes of the Study

All values in median (interquartile range), unless mentioned. VAS = visual analog scale.

The result of this large RCT demonstrates that 1% and 2% concentrations of lignocaine solution are equally effective in anesthetizing the airway. The bronchoscopist-reported VAS scores for cough were higher in the 1% lignocaine group; the difference although statistically significant is unlikely to be clinically relevant as the median difference of VAS score was merely four points on a scale ranging from 0 to 100. Moreover, the difference was not significant in the patients’ own assessment of their cough in the two groups. The pain rating was also not different in the two groups. The cumulative dose in the 1% arm was significantly lower compared with the other group. Thus, 1% lignocaine could achieve topical anesthesia during bronchoscopy as effectively as 2% but at a much lower dose compared with 2% lignocaine.

Most guidelines currently recommend performance of FB under IV sedation.9,10 However, in our center, due to high patient load and lower doctor-to-patient ratio, basic diagnostic procedures such as BAL, EBB, and TBLB are performed under topical anesthesia without any IV sedation. Although sedation should be used wherever possible,3,14 local anesthesia can be achieved within 2 min of endotracheal lignocaine application, which blunts the cough reflex effectively,15 allowing for safe and comfortable performance of FB.16

Few studies have evaluated the effective lignocaine concentration for topical anesthesia during FB (Table 4).11,1719 Of the four, one has been published only as an abstract while three are peer reviewed.19 Of the three peer-reviewed studies, only a single study was performed in the bronchoscopy suite, while the other two studies were conducted in the operating suite and are, thus, different from the routine practice in the bronchoscopy suite. The results of these studies suggest that 2% is as efficacious as 4% solution while 1% is as effective at 2% lignocaine. The limitation of these studies apart from differing methodologies is the small sample size. The results of our study supplement these studies and confirm that 1% lignocaine solution is as efficacious as 2% but has the added advantage of effectiveness at significantly lower cumulative dose. These findings are important for routine practice as there are reported cases of death from presumed lignocaine toxicity after FB.20,21 In fact, 28% of patients in the 2% lignocaine arm of our study exceeded the dose of > 8.2 mg/kg, recommended as the maximum dose by the British Thoracic Society.22 In another study, the anesthetists used doses of up to 14.8 mg/kg lignocaine by a spray-as-you-go method in a study involving volunteer subjects undergoing awake fiber-optic intubation; some volunteers were reported to have experienced involuntary movements, symptoms that may precede convulsions, which is a sign of lignocaine toxicity.23 The pharmacokinetics of topical lignocaine during FB are complex and can be influenced by several factors, including the duration and frequency of suctioning.24 This means that the plasma levels achieved in an individual patient are often unpredictable.2529 However, the propensity would increase with increasing doses of lignocaine used. By using 1% lignocaine, the risk of potential toxicity would be lower although it is still essential to carefully monitor the amount of lignocaine administered during FB. Another important benefit of a lower concentration would be the usage in patients with renal and hepatic dysfunction, as well as in patients with airway inflammation and pediatric age group, as the dose would be minimized.

Table Graphic Jump Location
TABLE 4 ]  Studies Evaluating Different Lignocaine Concentrations for Topical Anesthesia During FB

RCT = randomized controlled trial. See Table 2 and 3 legends for expansion of other abbreviations.

Finally, our study is not without limitations. There were several factors in our study that could affect the outcomes. These were multiple operators (consultants, fellows), variable duration of bronchoscopy, wide range of indications, and concomitant procedures. However, they were equally distributed between the two groups. The other limitation could be the lack of widespread generalization of our results given the fact that IV sedation was not used while a vast majority of bronchoscopists use sedation. However, lack of sedation can also be regarded as a major strength of the study as it allowed a clear assessment of the cough severity by the patient in contrast to the previous study where the patients were sedated.11 The other obvious strength of the study is the large sample size.

In conclusion, the results of this study suggest that 1% lignocaine is similar in efficacy to 2% lignocaine for topical anesthesia during FB, at significantly lower doses of lignocaine. Hence, 1% lignocaine should be the preferred concentration for topical anesthesia of the larynx and the tracheobronchial tree during FB.

Author contributions: R. A. is the guarantor of the paper, taking responsibility for the integrity of the work as a whole, from inception to published article. H. K. contributed to data collection as well as drafting of the manuscript; S. D. and A. N. A. contributed to patient management, data collection, and revision of the manuscript for intellectual content; D. G. and D. B. contributed to patient management and revision of the manuscript; and R. A. conceived the idea and contributed to patient management as well as drafting and revision of the manuscript for intellectual content.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

EBB

endobronchial biopsy

FB

flexible bronchoscopy

RCT

randomized controlled trial

TBLB

transbronchial lung biopsy

TBNA

transbronchial needle aspiration

VAS

visual analog scale

Casal RF, Ost DE, Eapen GA. Flexible bronchoscopy. Clin Chest Med. 2013;34(3):341-352. [CrossRef] [PubMed]
 
Hadzri H, Azarisman S, Fauzi A, et al. Can a bronchoscopist reliably assess a patient’s experience of bronchoscopy? JRSM Short Rep. 2010;1(4):35. [CrossRef] [PubMed]
 
Stolz D, Chhajed PN, Leuppi JD, Brutsche M, Pflimlin E, Tamm M. Cough suppression during flexible bronchoscopy using combined sedation with midazolam and hydrocodone: a randomised, double blind, placebo controlled trial. Thorax. 2004;59(9):773-776. [CrossRef] [PubMed]
 
Cox B, Durieux ME, Marcus MA. Toxicity of local anaesthetics. Best Pract Res Clin Anaesthesiol. 2003;17(1):111-136. [CrossRef] [PubMed]
 
Graham DR, Hay JG, Clague J, Nisar M, Earis JE. Comparison of three different methods used to achieve local anesthesia for fiberoptic bronchoscopy. Chest. 1992;102(3):704-707. [CrossRef] [PubMed]
 
Mendes de Leon C, Bezel R, Karrer W, Brändli O. Premedication in fiber optic bronchoscopy from the patient’s and the physician’s viewpoint—a randomized study for the comparison of midazolam and hydrocodone. [in German]. Schweiz Med Wochenschr. 1986;116(37):1267-1272. [PubMed]
 
Gjonaj ST, Lowenthal DB, Dozor AJ. Nebulized lidocaine administered to infants and children undergoing flexible bronchoscopy. Chest. 1997;112(6):1665-1669. [CrossRef] [PubMed]
 
Foster WM, Hurewitz AN. Aerosolized lidocaine reduces dose of topical anesthetic for bronchoscopy. Am Rev Respir Dis. 1992;146(2):520-522. [CrossRef] [PubMed]
 
Du Rand IA, Barber PV, Goldring J, et al; BTS Interventional Bronchoscopy Guideline Group. Summary of the British Thoracic Society guidelines for advanced diagnostic and therapeutic flexible bronchoscopy in adults. Thorax. 2011;66(11):1014-1015. [CrossRef] [PubMed]
 
Wahidi MM, Jain P, Jantz M, et al. American College of Chest Physicians consensus statement on the use of topical anesthesia, analgesia, and sedation during flexible bronchoscopy in adult patients. Chest. 2011;140(5):1342-1350. [CrossRef] [PubMed]
 
Hasmoni MH, Rani MFA, Harun R, Manap RA, Tajudin NAA, Anshar F. Randomized-controlled trial to study the equivalence of 1% versus 2% lignocaine in cough suppression and satisfaction during bronchoscopy. J Bronchology Interv Pulmonol. 2008;15(2):78-82.
 
Wewers ME, Lowe NK. A critical review of visual analogue scales in the measurement of clinical phenomena. Res Nurs Health. 1990;13(4):227-236. [CrossRef] [PubMed]
 
Hockenberry MJ, Wilson D. Wong’s Essentials of Pediatric Nursing.8th ed. St. Louis, MO: Mosby; 2009.
 
Maguire GP, Rubinfeld AR, Trembath PW, Pain MC. Patients prefer sedation for fibreoptic bronchoscopy. Respirology. 1998;3(2):81-85. [CrossRef] [PubMed]
 
Pani N, Kumar Rath S. Regional & topical anaesthesia of upper airways. Indian J Anaesth. 2009;53(6):641-648. [PubMed]
 
Hatton MQ, Allen MB, Vathenen AS, Mellor E, Cooke NJ. Does sedation help in fibreoptic bronchoscopy? BMJ. 1994;309(6963):1206-1207. [CrossRef] [PubMed]
 
Mainland PA, Kong AS, Chung DC, Chan CH, Lai CK. Absorption of lidocaine during aspiration anesthesia of the airway. J Clin Anesth. 2001;13(6):440-446. [CrossRef] [PubMed]
 
Xue FS, Liu HP, He N, et al. Spray-as-you-go airway topical anesthesia in patients with a difficult airway: a randomized, double-blind comparison of 2% and 4% lidocaine. Anesth Analg. 2009;108(2):536-543. [CrossRef] [PubMed]
 
Bansal A, Maqbool S, Jha R. A study on clinical efficacy of 1% versus 2% lignocaine in cough suppression and patient satisfaction during fiber-optic bronchoscopy. Chest. 2011;140(4_MeetingAbstracts):869A. [CrossRef]
 
Day RO, Chalmers DR, Williams KM, Campbell TJ. The death of a healthy volunteer in a human research project: implications for Australian clinical research. Med J Aust. 1998;168(9):449-451. [PubMed]
 
Wu FL, Razzaghi A, Souney PF. Seizure after lidocaine for bronchoscopy: case report and review of the use of lidocaine in airway anesthesia. Pharmacotherapy. 1993;13(1):72-78. [PubMed]
 
British Thoracic Society Bronchoscopy Guidelines Committee, a Subcommittee of Standards of Care Committee of British Thoracic Society. British Thoracic Society guidelines on diagnostic flexible bronchoscopy. Thorax. 2001;56(suppl 1):i1-i21. [PubMed]
 
Martin KM, Larsen PD, Segal R, Marsland CP. Effective nonanatomical endoscopy training produces clinical airway endoscopy proficiency. Anesth Analg. 2004;99(3):938-944. [CrossRef] [PubMed]
 
Williams KA, Barker GL, Harwood RJ, Woodall NM. Combined nebulization and spray-as-you-go topical local anaesthesia of the airway. Br J Anaesth. 2005;95(4):549-553. [CrossRef] [PubMed]
 
Sutherland AD, Santamaria JD, Nana A. Patient comfort and plasma lignocaine concentrations during fibreoptic bronchoscopy. Anaesth Intensive Care. 1985;13(4):370-374. [PubMed]
 
Sutherland AD, Williams RT. Cardiovascular responses and lidocaine absorption in fiberoptic-assisted awake intubation. Anesth Analg. 1986;65(4):389-391. [CrossRef] [PubMed]
 
Efthimiou J, Higenbottam T, Holt D, Cochrane GM. Plasma concentrations of lignocaine during fibreoptic bronchoscopy. Thorax. 1982;37(1):68-71. [CrossRef] [PubMed]
 
Langmack EL, Martin RJ, Pak J, Kraft M. Serum lidocaine concentrations in asthmatics undergoing research bronchoscopy. Chest. 2000;117(4):1055-1060. [CrossRef] [PubMed]
 
Loukides S, Katsoulis K, Tsarpalis K, Panagou P, Kalogeropoulos N. Serum concentrations of lignocaine before, during and after fiberoptic bronchoscopy. Respiration. 2000;67(1):13-17. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  CONSORT diagram demonstrating the flow of participants in the study. EBUS = endobronchial ultrasonography; TBNA = transbronchial needle aspiration.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Baseline Characteristics of the Study Population

All values are expressed as median with interquartile range, unless otherwise stated.

Table Graphic Jump Location
TABLE 2 ]  Serial Physiologic Parameters Measured Before, During, and After FB in the Two Groups

All values are mean (SD) unless otherwise stated. P < .05 was taken as significant. The differences between the means was analyzed using multiple repeated measure analysis of variance with Bonferroni adjustment for multiple comparisons; the within-groups factor was time (baseline, during, and after), and the between-groups factor was the lignocaine groups (1% vs 2%). FB = flexible bronchoscopy.

a 

Value during procedure significantly different from that at baseline within the groups.

b 

Value after procedure significantly different from that at baseline within the groups.

Table Graphic Jump Location
TABLE 3 ]  Primary and Secondary Outcomes of the Study

All values in median (interquartile range), unless mentioned. VAS = visual analog scale.

Table Graphic Jump Location
TABLE 4 ]  Studies Evaluating Different Lignocaine Concentrations for Topical Anesthesia During FB

RCT = randomized controlled trial. See Table 2 and 3 legends for expansion of other abbreviations.

References

Casal RF, Ost DE, Eapen GA. Flexible bronchoscopy. Clin Chest Med. 2013;34(3):341-352. [CrossRef] [PubMed]
 
Hadzri H, Azarisman S, Fauzi A, et al. Can a bronchoscopist reliably assess a patient’s experience of bronchoscopy? JRSM Short Rep. 2010;1(4):35. [CrossRef] [PubMed]
 
Stolz D, Chhajed PN, Leuppi JD, Brutsche M, Pflimlin E, Tamm M. Cough suppression during flexible bronchoscopy using combined sedation with midazolam and hydrocodone: a randomised, double blind, placebo controlled trial. Thorax. 2004;59(9):773-776. [CrossRef] [PubMed]
 
Cox B, Durieux ME, Marcus MA. Toxicity of local anaesthetics. Best Pract Res Clin Anaesthesiol. 2003;17(1):111-136. [CrossRef] [PubMed]
 
Graham DR, Hay JG, Clague J, Nisar M, Earis JE. Comparison of three different methods used to achieve local anesthesia for fiberoptic bronchoscopy. Chest. 1992;102(3):704-707. [CrossRef] [PubMed]
 
Mendes de Leon C, Bezel R, Karrer W, Brändli O. Premedication in fiber optic bronchoscopy from the patient’s and the physician’s viewpoint—a randomized study for the comparison of midazolam and hydrocodone. [in German]. Schweiz Med Wochenschr. 1986;116(37):1267-1272. [PubMed]
 
Gjonaj ST, Lowenthal DB, Dozor AJ. Nebulized lidocaine administered to infants and children undergoing flexible bronchoscopy. Chest. 1997;112(6):1665-1669. [CrossRef] [PubMed]
 
Foster WM, Hurewitz AN. Aerosolized lidocaine reduces dose of topical anesthetic for bronchoscopy. Am Rev Respir Dis. 1992;146(2):520-522. [CrossRef] [PubMed]
 
Du Rand IA, Barber PV, Goldring J, et al; BTS Interventional Bronchoscopy Guideline Group. Summary of the British Thoracic Society guidelines for advanced diagnostic and therapeutic flexible bronchoscopy in adults. Thorax. 2011;66(11):1014-1015. [CrossRef] [PubMed]
 
Wahidi MM, Jain P, Jantz M, et al. American College of Chest Physicians consensus statement on the use of topical anesthesia, analgesia, and sedation during flexible bronchoscopy in adult patients. Chest. 2011;140(5):1342-1350. [CrossRef] [PubMed]
 
Hasmoni MH, Rani MFA, Harun R, Manap RA, Tajudin NAA, Anshar F. Randomized-controlled trial to study the equivalence of 1% versus 2% lignocaine in cough suppression and satisfaction during bronchoscopy. J Bronchology Interv Pulmonol. 2008;15(2):78-82.
 
Wewers ME, Lowe NK. A critical review of visual analogue scales in the measurement of clinical phenomena. Res Nurs Health. 1990;13(4):227-236. [CrossRef] [PubMed]
 
Hockenberry MJ, Wilson D. Wong’s Essentials of Pediatric Nursing.8th ed. St. Louis, MO: Mosby; 2009.
 
Maguire GP, Rubinfeld AR, Trembath PW, Pain MC. Patients prefer sedation for fibreoptic bronchoscopy. Respirology. 1998;3(2):81-85. [CrossRef] [PubMed]
 
Pani N, Kumar Rath S. Regional & topical anaesthesia of upper airways. Indian J Anaesth. 2009;53(6):641-648. [PubMed]
 
Hatton MQ, Allen MB, Vathenen AS, Mellor E, Cooke NJ. Does sedation help in fibreoptic bronchoscopy? BMJ. 1994;309(6963):1206-1207. [CrossRef] [PubMed]
 
Mainland PA, Kong AS, Chung DC, Chan CH, Lai CK. Absorption of lidocaine during aspiration anesthesia of the airway. J Clin Anesth. 2001;13(6):440-446. [CrossRef] [PubMed]
 
Xue FS, Liu HP, He N, et al. Spray-as-you-go airway topical anesthesia in patients with a difficult airway: a randomized, double-blind comparison of 2% and 4% lidocaine. Anesth Analg. 2009;108(2):536-543. [CrossRef] [PubMed]
 
Bansal A, Maqbool S, Jha R. A study on clinical efficacy of 1% versus 2% lignocaine in cough suppression and patient satisfaction during fiber-optic bronchoscopy. Chest. 2011;140(4_MeetingAbstracts):869A. [CrossRef]
 
Day RO, Chalmers DR, Williams KM, Campbell TJ. The death of a healthy volunteer in a human research project: implications for Australian clinical research. Med J Aust. 1998;168(9):449-451. [PubMed]
 
Wu FL, Razzaghi A, Souney PF. Seizure after lidocaine for bronchoscopy: case report and review of the use of lidocaine in airway anesthesia. Pharmacotherapy. 1993;13(1):72-78. [PubMed]
 
British Thoracic Society Bronchoscopy Guidelines Committee, a Subcommittee of Standards of Care Committee of British Thoracic Society. British Thoracic Society guidelines on diagnostic flexible bronchoscopy. Thorax. 2001;56(suppl 1):i1-i21. [PubMed]
 
Martin KM, Larsen PD, Segal R, Marsland CP. Effective nonanatomical endoscopy training produces clinical airway endoscopy proficiency. Anesth Analg. 2004;99(3):938-944. [CrossRef] [PubMed]
 
Williams KA, Barker GL, Harwood RJ, Woodall NM. Combined nebulization and spray-as-you-go topical local anaesthesia of the airway. Br J Anaesth. 2005;95(4):549-553. [CrossRef] [PubMed]
 
Sutherland AD, Santamaria JD, Nana A. Patient comfort and plasma lignocaine concentrations during fibreoptic bronchoscopy. Anaesth Intensive Care. 1985;13(4):370-374. [PubMed]
 
Sutherland AD, Williams RT. Cardiovascular responses and lidocaine absorption in fiberoptic-assisted awake intubation. Anesth Analg. 1986;65(4):389-391. [CrossRef] [PubMed]
 
Efthimiou J, Higenbottam T, Holt D, Cochrane GM. Plasma concentrations of lignocaine during fibreoptic bronchoscopy. Thorax. 1982;37(1):68-71. [CrossRef] [PubMed]
 
Langmack EL, Martin RJ, Pak J, Kraft M. Serum lidocaine concentrations in asthmatics undergoing research bronchoscopy. Chest. 2000;117(4):1055-1060. [CrossRef] [PubMed]
 
Loukides S, Katsoulis K, Tsarpalis K, Panagou P, Kalogeropoulos N. Serum concentrations of lignocaine before, during and after fiberoptic bronchoscopy. Respiration. 2000;67(1):13-17. [CrossRef] [PubMed]
 
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